Obstetric Emergencies
Uterine rupture is a complete or partial tearing of the uterine wall, often resulting in the escape of the fetus and amniotic fluid into the peritoneal cavity. It may involve the endometrium, myometrium, and serosa, and sometimes the bladder if the lower segment is affected.
Definition
Uterine rupture is a complete or partial tearing of the uterine wall, often resulting in the escape of the fetus and amniotic fluid into the peritoneal cavity.
It may involve the endometrium, myometrium, and serosa, and sometimes the bladder if the lower segment is affected.
Classification
| Type | Description |
|---|---|
| 1. Complete rupture | All layers of the uterus (endometrium, myometrium, serosa) are torn; uterine contents spill into the peritoneal cavity. |
| 2. Incomplete rupture (dehiscence) | Tear involves endometrium and myometrium but serosa remains intact; fetus remains inside the uterus. |
Incidence
- Rare but highly fatal if missed — accounts for ~5–10% of maternal deaths in some regions.
- More common in scarred uteri (e.g., after cesarean section or myomectomy).
Etiology (Causes)
A. Predisposing (Risk) Factors
1. Previous Uterine Surgery
- Previous cesarean section (especially classical or vertical incision)
- Previous myomectomy or uterine perforation
2. Labour-related Causes
- Obstructed labour due to cephalopelvic disproportion (CPD)
- Excessive uterine stimulation with oxytocin or prostaglandins
- Instrumental delivery with traction or fundal pressure
3. Trauma
- Accidental injury during delivery
- External trauma (e.g., road traffic accident)
4. Congenital or Pathological Weakness
- Congenital uterine anomaly
- Grand multiparity (uterine wall thinning)
- Placenta percreta invading the wall
A. Predisposing (Risk) Factors
1. Previous Uterine Surgery
- Previous cesarean section (especially classical or vertical incision)
- Previous myomectomy or uterine perforation
2. Labour-related Causes
- Obstructed labour due to cephalopelvic disproportion (CPD)
- Excessive uterine stimulation with oxytocin or prostaglandins
- Instrumental delivery with traction or fundal pressure
3. Trauma
- Accidental injury during delivery
- External trauma (e.g., road traffic accident)
4. Congenital or Pathological Weakness
- Congenital uterine anomaly
- Grand multiparity (uterine wall thinning)
- Placenta percreta invading the wall
Pathophysiology
In obstructed labour or scarred uterus, continuous uterine contractions build up high intrauterine pressure.
This causes the weakened wall to tear, leading to:
- Massive internal bleeding
- Fetal extrusion into the abdomen
- Maternal shock
Clinical Features
A. Warning (Impending Rupture)
Before actual rupture, especially in obstructed labour:
- Maternal distress, anxiety, restlessness
- Severe lower abdominal pain
- Tender, hypertonic uterus ("Bandl's ring" visible — upper segment contracts, lower segment thins)
- Vaginal bleeding or hematuria
- Rising pulse and falling BP
- Fetal distress or decelerations on CTG
If not relieved, this progresses rapidly to rupture.
B. After Rupture
- Sudden, tearing abdominal pain
- Cessation of contractions (uterus relaxes)
- Fetal parts easily palpable under the abdominal wall (fetus outside uterus)
- Loss of fetal station (presenting part moves upwards)
- Vaginal bleeding (may be internal or external)
- Shock — out of proportion to visible blood loss
- Fetal heart sounds absent
A. Warning (Impending Rupture)
Before actual rupture, especially in obstructed labour:
- Maternal distress, anxiety, restlessness
- Severe lower abdominal pain
- Tender, hypertonic uterus ("Bandl's ring" visible — upper segment contracts, lower segment thins)
- Vaginal bleeding or hematuria
- Rising pulse and falling BP
- Fetal distress or decelerations on CTG
If not relieved, this progresses rapidly to rupture.
B. After Rupture
- Sudden, tearing abdominal pain
- Cessation of contractions (uterus relaxes)
- Fetal parts easily palpable under the abdominal wall (fetus outside uterus)
- Loss of fetal station (presenting part moves upwards)
- Vaginal bleeding (may be internal or external)
- Shock — out of proportion to visible blood loss
- Fetal heart sounds absent
Diagnosis
Mainly clinical, especially in labour.
If the patient survives initial rupture:
- Ultrasound may show fetus outside uterine cavity or discontinuity in the uterine wall.
But clinical suspicion is paramount — do not delay surgery for imaging if rupture is suspected.
Complications
Maternal
- Hemorrhagic shock
- Disseminated intravascular coagulation (DIC)
- Infection or peritonitis
- Bladder injury
- Death
Fetal
- Fetal hypoxia and death (mortality >90% in complete rupture)
Management
Immediate action is life-saving — "Resuscitate first, operate fast."
Step 1 – Resuscitation
- Call for help immediately (obstetric, surgical, anesthetic teams).
- ABC protocol: secure airway, give oxygen, establish 2 large IV lines.
- Start IV fluids (crystalloids) and blood transfusion.
- Monitor vitals and urine output (catheterize).
Simultaneously prepare for emergency laparotomy.
Step 2 – Laparotomy (Definitive Management)
Under general anesthesia:
| Findings | Management Option |
|---|---|
| Rupture small and repairable; uterus otherwise healthy | Repair of the tear (uterine repair) ± tubal ligation |
| Extensive rupture / uncontrollable bleeding / poor tissue | Subtotal or total hysterectomy |
| Bladder injury | Repair bladder at the same time |
Fetus: usually delivered during laparotomy (often already dead).
Step 3 – Postoperative Care
- Continue IV fluids, antibiotics, and blood transfusion as required.
- Monitor vitals and urine output closely.
- Provide psychological counseling — risk of recurrence in future pregnancies.
- Advise elective cesarean for future deliveries.
Step 1 – Resuscitation
- Call for help immediately (obstetric, surgical, anesthetic teams).
- ABC protocol: secure airway, give oxygen, establish 2 large IV lines.
- Start IV fluids (crystalloids) and blood transfusion.
- Monitor vitals and urine output (catheterize).
Simultaneously prepare for emergency laparotomy.
Step 2 – Laparotomy (Definitive Management)
Under general anesthesia:
| Findings | Management Option |
|---|---|
| Rupture small and repairable; uterus otherwise healthy | Repair of the tear (uterine repair) ± tubal ligation |
| Extensive rupture / uncontrollable bleeding / poor tissue | Subtotal or total hysterectomy |
| Bladder injury | Repair bladder at the same time |
Fetus: usually delivered during laparotomy (often already dead).
Step 3 – Postoperative Care
- Continue IV fluids, antibiotics, and blood transfusion as required.
- Monitor vitals and urine output closely.
- Provide psychological counseling — risk of recurrence in future pregnancies.
- Advise elective cesarean for future deliveries.
Prevention
Antenatal
- Identify and monitor high-risk women (previous uterine scar).
- Advise hospital delivery with facilities for emergency cesarean.
Intrapartum
- Avoid induction or augmentation in scarred uterus unless essential.
- Continuous fetal monitoring during labour.
- Do not use excessive oxytocin or fundal pressure.
- Perform cesarean promptly if obstructed labour suspected.
Prognosis
- Maternal mortality: up to 5–10% even with prompt care.
- Fetal mortality: 80–95% (due to acute asphyxia).
- Survivors often need cesarean section in subsequent pregnancies.
Summary (High-Yield Points)
- Definition: tearing of uterine wall — complete or incomplete.
- Most common cause: previous cesarean scar rupture or obstructed labour.
- Warning signs: abdominal pain, Bandl's ring, fetal distress, vaginal bleeding.
- After rupture: loss of contractions, palpable fetal parts, maternal shock.
- Management: immediate resuscitation → emergency laparotomy → repair or hysterectomy.
- Never delay surgery for investigation.
- Prevention: avoid obstructed labour, cautious use of oxytocin, hospital delivery for scarred uterus.